Benevolent Request

I am requesting material assistance from the Woodstock Community Church and by filling out this form and submitting this form, I understand that I am authorizing the release of information about me to the below named organizations:

Consent to Release Personal Information to the Following Organizations:

* Pipestone Ministerial Association Members * Pipestone and Maury County Sheriff’s Office * SWHHS- Pipestone & Maury Co. * Volunteers In Mercy (VIM) * Housing & Redevelopment Authority of Pipestone and Maury Co. * ATLAS for LIFE

Note: If any of the above organizations believes I am misrepresenting my need for this assistance; I UNDERSTAND THAT NO FURTHER HELP WILL BE GRANTED.

I also understand that after my household received assistance twice, financial mentoring will be required before futher assistance will be considered. These mentoring/budgeting sessions will consist of two 1 1/2 hour meetings at “ATLAS for LIFE” office in Pipestone or by the Woodstock Community Church Staff.

(By submitting this request form I am stating that I have read the above, agree with the terms and that the below information is accurate.)